| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
3,125 |
508 |
$107K |
| D9248 |
|
306 |
305 |
$81K |
| D1120 |
Prophylaxis - child |
1,604 |
1,593 |
$58K |
| D0120 |
Periodic oral evaluation - established patient |
2,051 |
2,035 |
$58K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
316 |
179 |
$49K |
| D1206 |
Topical application of fluoride varnish |
2,295 |
2,275 |
$47K |
| D1110 |
Prophylaxis - adult |
812 |
810 |
$44K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
361 |
214 |
$33K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
268 |
152 |
$30K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
552 |
547 |
$29K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
342 |
184 |
$27K |
| D7140 |
Extraction, erupted tooth or exposed root |
299 |
172 |
$21K |
| D0272 |
Bitewings - two radiographic images |
710 |
707 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
331 |
331 |
$13K |
| D0274 |
Bitewings - four radiographic images |
357 |
356 |
$12K |
| D2140 |
|
131 |
95 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
555 |
547 |
$7K |
| D1310 |
|
367 |
367 |
$5K |
| D1330 |
|
254 |
254 |
$3K |
| D0330 |
Panoramic radiographic image |
56 |
56 |
$3K |
| D9110 |
|
14 |
13 |
$739.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
78 |
46 |
$668.53 |
| D0270 |
|
25 |
24 |
$384.80 |
| D1320 |
|
53 |
53 |
$10.00 |